(3) IF A SPECIALIST ACTS AS THE PRIMARY CARE COORDINATOR FOR A
MEMBER IN ACCORDANCE WITH THIS SUBSECTION, THE SPECIALIST SHALL:

(I) ACT IN ACCORDANCE WITH A WRITTEN TREATMENT PLAN
THAT IS APPROVED BY THE CARRIER IN CONSULTATION WITH: FOR A COVERED
SERVICE DEVELOPED BY:

1. THE PRIMARY CARE PROVIDER PHYSICIAN;

2. THE SPECIALIST; AND

3. THE MEMBER; AND

(II) COMMUNICATE REGULARLY WITH THE PRIMARY CARE
PROVIDER PHYSICIAN REGARDING THE TREATMENT AND HEALTH STATUS OF THE
MEMBER.

(D) (C) (1) EACH CARRIER SHALL ESTABLISH AND IMPLEMENT A
PROCEDURE BY WHICH A MEMBER MAY REQUEST A REFERRAL TO A SPECIALIST
WHO IS NOT PART OF THE CARRIER'S PROVIDER PANEL IN ACCORDANCE WITH THIS
SUBSECTION.

(2) THE PROCEDURE SHALL PROVIDE FOR A REFERRAL TO A SPECIALIST
WHO IS NOT PART OF THE CARRIER'S PROVIDER PANEL IF:

(I) THE MEMBER IS DIAGNOSED WITH A CONDITION OR DISEASE
THAT REQUIRES SPECIALIZED MEDICAL CARE;

(II) THE CARRIER DOES NOT HAVE IN ITS PROVIDER PANEL A
SPECIALIST WITH THE SAME PROFESSIONAL TRAINING AND EXPERTISE AS THE
SPECIALIST FROM WHOM THE MEMBER SEEKS TREATMENT; TO TREAT THE
CONDITION OR DISEASE; AND

(III) THE SPECIALIST HAS EXPERTISE IN TREATING THE DISEASE OR
CONDITION; AND

(IV) THE SPECIALIST AGREES TO ACCEPT THE SAME
REIMBURSEMENT AS WOULD BE PROVIDED TO A SPECIALIST WHO IS PART OF THE
CARRIER'S PROVIDER PANEL.

(E) A DECISION BY A CARRIER NOT TO PROVIDE ACCESS TO OR COVERAGE OF
TREATMENT BY A SPECIALIST UNDER A PROCEDURE REQUIRED UNDER THIS
SECTION CONSTITUTES AN ADVERSE DECISION AS DEFINED UNDER SUBTITLE 10A
OF THIS TITLE.

(E) (D) A DECISION BY A CARRIER NOT TO PROVIDE ACCESS TO OR
COVERAGE OF TREATMENT BY A SPECIALIST IN ACCORDANCE WITH THIS SECTION
CONSTITUTES AN ADVERSE DECISION AS DEFINED UNDER SUBTITLE 10A OF THIS
TITLE IF THE DECISION IS BASED ON A FINDING THAT THE PROPOSED SERVICE IS
NOT MEDICALLY NECESSARY, APPROPRIATE, OR EFFICIENT.

m (E) EACH CARRIER SHALL FILE WITH THE COMMISSIONER A COPY OF
EACH OF THE PROCEDURES REQUIRED UNDER THIS SECTION.